A physician may notice behaviors with certain patients that are atypical for their usual customary medical practice. These unusual physician behaviors should trigger self-examination by the physician and consideration that the patient may have a personality or somatoform disorder. Frequently, difficult patients are capable of arousing unconscious reactions that lead to new and unusual physician behaviors.
Common atypical physician behaviors may include ordering tests to placate a patient, asking for more than the usual number of consults on a patient whose case does not seem medically complicated, suggesting increasingly aggressive diagnostic testing or procedures when the yield of these tests is likely to be low, repeatedly extending the time spent with a particular patient or family, lowering the customary fee, offering free treatment, or developing a personal (not professional) relationship with a patient. Common physician reactions associated with difficult patients are reviewed in Table 46-2.
Physicians can use the scope of patient-generated countertransferences (their feelings, fantasies, and atypical medical behaviors) as a valuable diagnostic aid, because difficult patients tend to provoke the same feelings in most physicians who deal with them. For example, a patient with a borderline personality disorder often leaves many physicians exhausted and worried about the patient's suicidal threats. A patient with multiple somatic complaints may leave physicians feeling frustrated that they cannot alleviate the patient's pain symptoms or suffering. Physicians who learn to recognize feelings provoked by patients will find it easier to identify the subtype of difficult patients according to the feelings elicited. More importantly, physicians who can recognize their unusual reactions will be better able to tolerate them and avoid acting out their feelings with a patient. This will improve the physician-patient relationship, medical decision making, and ultimately patient care (Feinstein et al., 1999).
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